Assessing the transition from intravenous to subcutaneous delivery of rituximab: Benefits for payers, health care professionals, and patients with lymphoma

Subcutaneous (SC) administration of rituximab provides an opportunity for reduced patient treatment burden and increased healthcare efficiencies as an alternative to intravenous (IV) rituximab. There is minimal evidence comparing costs associated with SC and IV rituximab in a US setting. This research assessed the impact of transitioning patients from IV to SC rituximab for treatment of non-Hodgkin’s lymphoma (NHL) from the US payer, provider, and patient perspective. We developed a model to estimate cost differences for transitioning 20% of a patient cohort from IV to SC rituximab. We included patients with incident diffuse large B-cell lymphoma, incident and recurrent follicular lymphoma, and incident and recurrent chronic lymphocytic leukemia. In the model, each patient received the same number of doses and that there was no difference in discontinuation between cohorts due to non-inferior efficacy and a similar safety profile. Model inputs were collected from published literature and publicly available data. Scenario analyses tested the impact of availability of low-cost biosimilars. In the base case (1,000,000 covered lives), we estimated a total of 157 patients, with 769 total drug administrations. A transition of 20% of patients from IV to SC was projected to generate $153,000 in payer savings, increase provider capacity by 270 hours, and free 470 hours of patient time. Scenario analyses suggest SC administration will be cost saving for payers even with a market where biosimilars approach 50% market share. A 20% transition to SC rituximab in a single cohort of patients has the potential to generate significant US health system value in the form of payer savings, increased practice capacity, and patient time.

Budget Impact Analysis of Comprehensive Genomic Profiling in Patients With Advanced Non-Small-Cell Lung Cancer

PURPOSE

This study assessed the economic impact of increased use of comprehensive genomic profiling (CGP) versus conventional testing strategies among patients with advanced non-small-cell lung cancer (aNSCLC) from a US commercial health plan perspective.

METHODS

A decision analytic model was developed to estimate the incremental benefits and costs across testing methodologies (CGP v non-CGP), as well as across sample types (tissue-based and liquid-based), for patients with newly diagnosed aNSCLC. Model outcomes included total direct costs, testing costs, and per member per month budget impact. Secondary model outcomes included the number of patients needed to test with CGP to add 1 life-year, and the number of patients needed to test with CGP to treat one individual with a biomarker-matched therapy.

RESULTS

In a hypothetical 2,000,000-member health plan, 790 members were estimated to have incident aNSCLC; 609 underwent molecular diagnostic testing with 122 (20%) tested with CGP (109 tissue-based and 13 liquid) in the base-case. An increase in CGP from 20% to 30% (an additional 61 patients tested with CGP) was associated with 3.11 additional life-years gained and a $0.01 in US dollars per member per month budget impact. Approximately 19.6 patients would need to be tested with CGP versus non-CGP to add one life-year and 5.9 patients would need to be tested with CGP to treat at least one patient with a biomarker-matched therapy.

CONCLUSION

An increase in CGP from 20% to 30% among patients with aNSCLC undergoing molecular diagnostic testing was associated with modest budget impact, most of which was attributable to prolonged survival associated with increased use of more effective treatments.

The humanistic burden of postpartum depression: a systematic literature review

OBJECTIVE

Postpartum depression (PPD) is the most common medical complication of childbirth. PPD can be disabling, with potential negative effects on maternal health-related quality-of-life (HRQoL) as well as on children and partners. The objective of this study was to systematically review and summarize recently published literature describing the humanistic burden of PPD on affected women, their children, and partners.

METHODS

Databases including Embase, MEDLINE, and PsycINFO, as well as conference proceedings were searched for keywords related to PPD. Searches were initially conducted in February 2017 and restricted to the prior 5 years for databases and the prior 2 years for conference proceedings. Searches were updated in February 2018. Two researchers independently reviewed 1154 unique records according to pre-defined inclusion and exclusion screening criteria.

RESULTS

Forty-eight studies were identified; over 40 studies assessed the effects of PPD on children of affected mothers, with many demonstrating a negative association with elements of parenting and childhood development. Furthermore, five studies that evaluated the effects of PPD symptoms on partners suggested that certain aspects of their relationships were negatively affected. Partners of affected women also experienced greater levels of their own stress, anxiety, and depression compared with partners of women without PPD symptoms. Despite limited data on HRQoL among women with PPD symptoms (four studies), a negative impact on physical and mental sub-scales was observed.

CONCLUSIONS

Findings suggest that PPD symptoms have a substantial humanistic burden on affected mothers as well as on their children and partners.

Estimating the incremental net health benefit of requirements for cardiovascular risk evaluation for diabetes therapies

PURPOSE

To evaluate the advantages and disadvantages of pre-approval requirements for safety data to detect cardiovascular (CV) risk contained in the December 2008 U.S. Food and Drug Administration (FDA) guidance for developing type 2 diabetes drugs compared with the February 2008 FDA draft guidance from the perspective of diabetes population health.

METHODS

We applied the incremental net health benefit (INHB) framework to quantify the benefits and risks of investigational diabetes drugs using a common survival metric (life-years [LYs]). We constructed a decision analytic model for clinical program development consistent with the requirements of each guidance and simulated diabetes drugs, some of which had elevated CV risk. Assuming constant research budgets, we estimate the impact of increased trial size on drugs investigated. We aggregate treatment benefit and CV risks for each approved drug over a 35-year horizon under each guidance.

RESULTS

The quantitative analysis suggests that the December 2008 guidance adversely impacts diabetes population health. INHB was -1.80 million LYs, attributable to delayed access to diabetes therapies (-0 .18 million LYs) and fewer drugs (-1.64 million LYs), but partially offset by reduced CV risk exposure (0.02 million LYs). Results were robust in sensitivity analyses.

CONCLUSION

The health outcomes impact of all potential benefits and risks should be evaluated in a common survival measure, including health gain from avoided adverse events, lost health benefits from delayed or for gone efficacious products, and impact of alternative policy approaches. Quantitative analysis of the December 2008 FDA guidance for diabetes therapies indicates that negative impact on patient health will result.

Biologic disease-modifying drug treatment patterns and associated costs for patients with rheumatoid Arthritis

OBJECTIVE

To assess the influence of biologic treatment patterns on healthcare costs for patients with rheumatoid arthritis (RA) initiating tumor necrosis factor-α (TNF-α) antagonist therapy.

METHODS

Patients with 2 RA diagnoses (International Classification of Diseases, 9th ed, 714.xx), and without psoriasis or Crohn's disease, were identified in a US employer-based insurance claims database. A sample of 2545 was constructed based on an index event of initiating TNF-α antagonist therapy and 30 months of continuous enrollment. Baseline characteristics were assessed in the 6-month pre-index period and treatment patterns were determined during the 12-month post-index period. Medical service and prescription drug costs were analyzed for Months 13-24 using multivariate regression analysis to control for baseline characteristics and time-varying confounding associated with treatment and disease severity.

RESULTS

In the first year after TNF-α initiation, 89% used a single TNF-α antagonist; only 9% and 2% had switched TNF-α antagonists or received non-TNF biologic disease-modifying antirheumatic drugs, respectively. Descriptive analyses revealed pairwise differences between groups (p < 0.05) in baseline characteristics (comorbidities, RA-related procedure use, and prescription drug use). Controlling for observed baseline characteristics, costs were greater for those treated with multiple vs single TNF-α antagonists: annual RA-related prescription drug costs ($8,340 vs $7,058; p = 0.012), RA-related healthcare costs ($15,048 vs $13,312; p = 0.008), and total healthcare costs ($26,697 vs $21,381; p < 0.001).

CONCLUSION

In this sample, the majority of patients with RA were treated with a single TNF-α antagonist over the first year on therapy. For those who switched therapy, Year 2 RA-related and total direct healthcare costs were higher, adjusting for claims-based measures of RA disease severity.

Absenteeism among employees with irritable bowel syndrome

Patterns of illness or disability-related work absence six months before and six months after a diagnosis of irritable bowel syndrome (IBS) were assessed from medical claims and absenteeism databases and were compared with a sample of patients with no gastrointestinal (GI) disorders. The records of 630 patients with IBS were compared with those of 1,260 persons without GI conditions. Mean monthly IBS-related absences increased by 69% (from 0.96 to 1.62 days) from the beginning of the six-month period before diagnosis to the month of diagnosis. With multivariate regression analysis, the incremental effect of an IBS diagnosis on six-month absenteeism was estimated to be 3.27 absences greater for persons with IBS.

Developing Performance Measures for Prescription Drug Management

Prescription drug management plans are outpatient drug benefit programs that strive to manage the cost effective and clinically appropriate delivery of prescription drugs to beneficiaries. The demand for accountability and a means to evaluate performance of drug benefit management programs is growing; nevertheless, a set of valid, standardized indicators for evaluating performance does not exist. We review drug management program activities and identify available measures for assessing performance. Additionally, we note recent efforts to develop performance indicators for prescription drug management. We conclude by raising key questions that should be addressed before a comprehensive set of performance measures can be implemented.

Explaining drug spending trends: does perception match reality?

Several recent studies have made clear that drug expenditures are rising more rapidly than other health care spending. What has not been clear, however, is how much drug spending is driven by price rather than volume and whether volume increases are appropriate. This DataWatch takes a closer look at the components and drivers of drug spending using large claims databases from managed care and employer-sponsored health benefit plans. In both environments this study found volume, not price, to be the largest driver of drug spending for seven diseases studied. For four of the diseases, we review the clinical issues that may have influenced volume growth.

Absenteeism among employees treated for depression

Depression-related costs include a relatively large share of indirect costs. We describe the impact of antidepressant treatment on absenteeism among workers diagnosed and treated for depression. Monthly absenteeism counts from employers were summed in the 6 months before and after the initiation of antidepressant therapy in 630 workers treated for depression with a tricyclic antidepressant or a selective serotonin reuptake inhibitor (fluoxetine, sertraline, paroxetine). Monthly mean absenteeism was compared using pairwise t tests. Absenteeism increased before antidepressant initiation and decreased after the treatment began for all antidepressant cohorts. Absenteeism in the selective serotonin reuptake inhibitor cohorts decreased at similar rates for 4 months but was higher in the paroxetine cohort in months five and six after the treatment initiation. Our data suggest that alternative treatments for depression may have differential impact on indirect costs, but further research is warranted.

The effects of adherence to antidepressant treatment guidelines on relapse and recurrence of depression

BACKGROUND

Depression is associated with high rates of relapse and recurrence during a patient's lifetime. Current guidelines regarding treatment recommend 4 to 9 months of continuation antidepressant therapy following remission of acute symptoms to allow more complete resolution of the episode. In this article, we test whether adherence to these recommendations reduces the likelihood of relapse or recurrence in a Medicaid population.

METHODS

We used a Medicaid database covering 1989 through 1994. The sample consists of the 4052 adult patients who filled an antidepressant prescription at the time of an initial diagnosis of depression. These patients were followed up for up to 2 years. Timing and counts of antidepressant prescription claims are used to construct a proxy measure for adherence to guidelines. Relapse or recurrence is defined by evidence of a new episode requiring antidepressant treatment, hospital admission for depression, electroconvulsive therapy, emergency department visit for mental health, or attempted suicide. We used survival analysis to predict relapse or recurrence for each patient and to examine the effect of following treatment guidelines on relapse and recurrence.

RESULTS

Approximately one fourth of the patients had a relapse or recurrence during their follow-up period. Factors that affect relapse and recurrence include comorbidities, race, and guideline adherence. Those who continued therapy with their initial antidepressant were least likely to experience relapse or recurrence; those who discontinued their antidepressant early were most likely to experience relapse or recurrence.

CONCLUSION

Adherence to depression treatment guidelines with an antidepressant that is likely to have continuous use by patients reduces the probability of relapse or recurrence.

The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89

To increase the participation of Medicaid children in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and to improve their health, Congress included several provisions in the Omnibus Budget Reconciliation Act of 1989 (OBRA'89) that addressed problematic program features. The impact of these provisions on children's health service use was investigated in a study funded by the Health Care Financing Administration. After conducting site visits to four states, the authors analyzed claims data for the children residing there and found evidence that, in 1992, these states placed a higher priority on improving the effectiveness of EPSDT than they did before 1989. The states' efforts to expand the EPSDT provider base and to enhance outreach and service provision were either directly or indirectly inspired by OBRA'89. The authors also found evidence of a significant impact on provider participation and caseloads and on children's use of both preventive care and diagnostic and treatment services. However, the effects were modest in comparison to the size of the progress that is required.

Preventive Services for Children Under Medicaid, 1989 and 1992

Receipt of key preventive services among Medicaid children in four States is examined. Between 1989 and 1992, small-to-moderate improvements in well-child visit and immunization rates were observed. Age, eligibility group, and statewide factors affected these rates. Uniformly low use of preventive dental care was found. These rates were generally higher among children with well-child visits. To understand the full extent of preventive care for children, all Medicaid-financed well-child services should be considered, not just those provided under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services program. Nonetheless, EPSDT is a critical vehicle for outreach and case management.